Insurance Nightmare During Medical Crisis
I try to avoid thinking about that day. Even the smallest memory brings a deep pain that's difficult to describe. It was around 6 pm when I returned home from the office. My husband sat quietly at his work desk, reviewing his medical reports.
Two days earlier, doctors had diagnosed him with Hepatitis E. They prescribed rest, dietary changes, and some medications. We were waiting for a few test results but felt generally confident. The main diagnosis was clear, and we believed we could manage the situation effectively.
The Unexpected Diagnosis
While we talked, my husband received a call from the laboratory. His leptospirosis test had returned positive. I remembered the doctor mentioning this test earlier. He described it as a fairly common infectious disease and ordered it simply to eliminate all possibilities.
We didn't even know what leptospirosis was at that point. What disturbed us more than the unfamiliar name was the urgency in the lab technician's voice. He insisted we contact our doctor immediately.
We called the doctor, and fortunately, he answered. The moment he heard the disease name, his tone changed completely. He instructed my husband to seek hospital admission immediately.
Rushing to the Hospital
I asked my part-time house help to stay longer with our 11-year-old son. My mind felt foggy and unclear. I grabbed my wallet and rushed to Max Super Speciality Hospital in Patparganj. This was the nearest hospital to our home, and my husband had already received outpatient treatment there.
The doctor had alerted his team in advance. They attended to my husband immediately upon our arrival and began conducting tests. Amid the chaos, my husband tried to reassure me. He handed over his insurance details and asked me not to worry.
It was a policy worth ₹50 lakh. At that moment, we assumed it would cover all expenses completely.
The Insurance Shock
My husband had renewed the policy just one week earlier. We had examined all details thoroughly and felt quite satisfied. There seemed little reason for concern.
However, when I approached the billing counter, I received devastating news. This hospital no longer fell under the cashless panel of our insurance provider. This revelation came when my mind was already struggling to function clearly.
There was urgent pressure to complete billing so my husband's treatment could begin immediately. My salary account card contained very little money. I called the insurance coordinator from my office.
Understanding Leptospirosis
My husband had been diagnosed with leptospirosis. This rare bacterial infection comes from Leptospira bacteria. It typically spreads through water or soil contaminated by rat urine.
The disease becomes dangerous because it progresses very quickly. It requires immediate treatment and can worsen within hours. Potential complications include liver and kidney failure, internal bleeding, or lung problems.
Early diagnosis and immediate medical treatment are absolutely critical. Timely antibiotics can significantly reduce the risk of serious outcomes.
Unexpected Support
My life seemed to collapse at the billing counter. I called our office insurance coordinator. Thankfully, he answered immediately. He reassured me and asked for my office ID.
I was so shaken that I couldn't even recall it. He conducted his checks and asked me to submit a basic amount. He promised to speak with the TPA team and manage the rest.
At a time when I was literally trembling, unable to process facts and gripped by fear, this support felt like indescribable relief. This is what insurance should provide—not force you to change hospitals at the last moment or leave you stranded during a crisis.
Post-Treatment Realizations
Throughout my husband's treatment, I received full support from our office insurance coordinator. He even helped ensure we received the maximum possible amount from the insurance company during final settlement.
When my husband finally returned home, I spoke with the insurance agent who had charged us substantially for a policy that failed us during our greatest need. The response we received felt casual and dismissive: "Yeh ho jaata hai kabhi kabhi."
We had checked everything in the policy diligently before making payment. The first thing we verified was whether our nearest Max hospital was included in the network panel. The painful blow came from this last-minute change by the insurance company.
Lessons from My Experience
Hospital Network Changes
Yes, insurance companies can change their network hospital panels at any time, even after you purchase a policy. Insurers regularly update their hospital lists. A hospital that was in-network when you bought your policy could be removed later.
Contracts between insurers and hospitals undergo frequent renegotiation. If both parties cannot agree on rates, the hospital may be dropped from the network. This directly affects your access to cashless treatment.
The "Cashless Everywhere" Initiative
As of January 2024, the "Cashless Everywhere" initiative theoretically allows treatment at any hospital, even those outside your insurer's network. However, while many news pieces have reported this, I couldn't find official confirmation.
One publication even reported that it entirely depends on the hospital's prerogative. My question remains: Should families of patients need to do guesswork or research while struggling with a medical crisis?
Conditions for Non-Network Hospitals
While non-network hospitals are now included, you may need to inform your insurance company at least 48 hours in advance for planned procedures. For emergencies, you typically have 48 hours to notify them. But do emergencies come with a 48-hour warning?
Cashless vs Reimbursement Models
If a hospital exits the network, treatment may shift from cashless to reimbursement. This means you might need to pay upfront and claim the amount later. Again, the patient bears the burden, and the whole purpose of insurance gets compromised.
New Health Insurance Rule Changes
Important: Please verify all information with your insurance provider to avoid last-minute surprises.
- Cashless Treatment at Any Hospital: You may now receive cashless treatment even at hospitals outside your insurer's network. Previously, this benefit was limited to network hospitals. Disclaimer: Verify carefully as policies contain fine print that may override this.
- Faster Claim Clearance Timelines: Insurers must approve cashless claims within one hour of admission. They must settle final claims within three hours of discharge. Delays may require insurers to bear additional hospital charges.
- Reduced Waiting Period for Pre-existing Conditions: The waiting period for pre-existing diseases has decreased from four years to three years.
- Ayush Treatments Recognized: Health insurance policies must now cover Ayush treatments—Ayurveda, Yoga & Naturopathy, Unani, Siddha, and Homeopathy—subject to policy conditions.
- Shorter Moratorium Period: The moratorium period has been reduced from eight years to five years. After this period, claims cannot be denied due to non-disclosure except in cases of fraud.
- Claims Across Multiple Policies: If you hold multiple health insurance policies, you can combine them to settle a single hospitalisation bill.
For detailed guidelines, read the Master Circular on IRDAI (Insurance Products) Regulations 2024—Health Insurance dated: 29.05.2024.
About the Author
Smita Mishra serves as Editor of Times of India Lifestyle, Times Food, and Times Travel. She creates in-depth, compelling features that blend storytelling with analysis. Her passion lies in exploring culinary arts, travel, style, relationships, health, and literature through writing.
She leads TOI Books and oversees editorial aspects of Times of India's literary initiatives, including Times Literature Festivals and AutHer Awards. Smita brings extensive digital expertise from previous roles at Zee News, Dainik Jagran, and India Today. Her contributions have been pivotal in launching numerous online properties and making meaningful editorial enhancements.
